An estimated 48 million Americans live without health care coverage, which calculates to about 15.4 percent of the country’s population.
It was arguably in response to these statistics, among other factors, President Barack Obama put the Affordable Care Act (ObamaCare) into motion.
The act was made active at the beginning of 2014 and requires all Americans to have health insurance “whether through their employer or the individual market,” according to Money.CNN.com.
Senior citizens may be affected by ObamaCare because it touches directly on Medicare, a federal health insurance program offered to adults over 65 years old, and others, which consists of various “parts” that cover specific services.
Those who already have Original Medicare, known as Parts A and B, which cover medical and hospital care, can often also qualify for advantages, known as Part C.
Part C is often given through employers and takes the place of both Parts A and B because it covers hospital care, outpatient care and visits to the doctor, according to Medicare-plans.org.
A senior must choose to have Part C coverage, and a monthly premium is required. ObamaCare influences patients with Part C plans because it reduces the cost employers have to pay in order to obtain advantage programs.
However, Part D, which includes coverage for prescription drug plans, is really where ObamaCare takes effect.
In terms of senior citizens, the ACA aims to close a coverage gap of Part D or a “donut hole” that has previously prohibited seniors from affording their prescriptions.
A gap in coverage was caused by a limit imposed on many Medicare prescription drug plans, according to Medicare.gov.
Once an insured person has spent over $2,850, he or she reaches the coverage gap.
In years previous, a person would be required to pay the full amount owed after the gap was reached.
However, The ACA lends aid to those who reach the donut hole by only charging “47.5 percent of the plan’s cost for covered brand-name prescription drugs,” as stated on Medicare.gov.
People can acquire these savings by purchasing their medication at a pharmacy or ordering them online. In addition, the 47.5 percent paid is considered an “out-of-pocket” cost, which the insured person can report and use to get out of the cycle of gap coverage.
“The [closing of] the donut hole really does help people,” Jefferson County Human Services intern Jessica Coburn said. “I don’t think people even realize how much it helps them.”
ObamaCare and Whitewater’s elderly community
As a city that encompasses a handful of nursing homes, Whitewater, Wis., has its fair share of elderly citizens.
Dr. Kenneth Kidd, a specialist in geriatric medicine, provides care and prescribes medication for many seniors in the Whitewater area
Kidd said his patients will eventually benefit from the ACA and experience a difference in care when it comes to the closing donut hole.
However, despite closing the gap in Part D plans and adding affordable care for seniors, Economic Support Supervisor for Walworth County’s Department of Health & Human Services Carol Wicklund said, “The act does not have [much] of an impact on elderly, blind or disabled individuals [in Whitewater].”
Coburn explained, “ObamaCare doesn’t have a ton to do with Medicare because it’s already funded by a public program.”
Medicare recipients already purchase supplemental insurance, also known as Medigap insurance, which is sold by private companies and acts like Parts C and D to cover what Original Medicare doesn’t. Medigap can cover copayments, coinsurance and deductibles, according to Medicare.gov.
In other words, “[recipients of Medicare] are already in compliance with the law so they don’t need to do anything else,” Coburn said.
However, the act does not cover some elderly and disabled people because they are covered separately through an Elderly, Blind and Disabled plan, which is different from Medicare or Medicaid.
In terms of those on Medicare, Certified Nursing Assistant, at Fairhaven Senior Care, Julie Vodak said she hasn’t noticed much of a change in her patients’ medications, neither positively nor negatively.
“It’s not like someone is coming around and saying, ‘No, you cannot have your vitamin C,’” Vodak said.
It should be noted that Fairhaven, in particular, is not necessarily an accurate representation of the average “senior citizen” in a
nursing home, Director of Social Services Valerie Cole said.
“Many are retired college professors or professionals, so none have really had to deal with ObamaCare issues that community at
large people would,” Cole said. “They live on pensions, social security and investments.”
Several residents of Fairhaven have Medicare plans that are coupled with supplementary insurance. These high-quality Medicare plans, and the additional insurance, free them up from having to worry about reaching the donut hole.
Although the topic of ObamaCare has only recently exploded on the media, the reform has actually been on President Obama’s agenda since 2011.
In fact, for almost three years, through Part C coverage, the ACA has been preventing seniors from putting off doctor’s visits and screenings while giving them better access to cancer screenings, wellness visits, personalized prevention plans, vaccines, flu shots and more, according to Obamacarefacts.com.
Medicaid and Children’s Health Insurance Program (CHIP)
The law attached to ObamaCare also includes reforms to both Medicaid and the Children’s Health Insurance Program.
Both Medicaid and CHIP are related to BadgerCare in Wisconsin, according to Jill Johnson, the manager of Public Assistance for Jefferson County.
In addition to these services, a program known as Health Insurance Risk-Sharing Plan (HIRSP) is offered to Wisconsin residents who cannot find adequate health insurance due to preexisting medical conditions, according to HIRSP.org.
Wisconsin residents may qualify for HIRSP if they can properly document rejection from at least one insurer, are younger than 65 and are not eligible for employer-offered group health insurance.
In sum, “[BadgerCare, CHIP and HIRSP] refer to the budget that sends money to the state,” Johnson said.
Reforms on these programs involve two separate parts, the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).
According to Medicaid.org, both of these parts work together to expand Medicaid and CHIP coverage to millions of Americans with low incomes.
Medicaid and CHIP services provide assistance to over 60 million Americans including children, pregnant women, parents, seniors and individuals with disabilities.
Each state has discretion to administer and establish its own Medicaid programs. It can decide the type, amount, duration and scope of services.
ObamaCare’s affect on pharmaceuticals
Pharmacist Grant McCullough, of McCullough’s Prescriptions and Gifts in Whitewater, Wis., said he hasn’t necessarily seen any “direct” changes in his customers’ coverage. The “indirect” changes from the ACA mainly affect people who have disorders that require expensive medication to treat and prevent, he added.
“Prescription drug coverage varies and is based on the drug being taken,” McCullough said. “Some medications, like medication for high blood pressure, are dirt cheap and will still be dirt cheap when covered by insurance. Other disorders like muscular sclerosis, rheumatoid arthritis or diabetes can require thousands of dollars in medication costs.”
Some peoples’ medications are so inexpensive, in fact, that it costs them more to meet their deductibles than it does to obtain the actual medication.
While on the other hand, the people who pay hundreds of dollars for their medications meet their deductibles within a matter of months.
“That goes to the point of healthy people paying for non-healthy people,” McCullough said.
The federally-facilitated marketplace in Wisconsin
Under changes made by the ACA, the state of Wisconsin has decided to offer access to the Federally-Facilitated Marketplace.
Johnson said the FFM is first accessed and applied for on the healthcare.gov website.
“If someone applies and they are eligible, they get boosted to the access.wisconsin.gov site,” Johnson said.
Johnson’s job as the manager of public assistance requires her to look over all applications submitted by residents of Jefferson County.
According to CMS.gov, The FFM is implemented in states that have decided not to develop their own marketplaces.
FFM couples with Centers for Medicare & Medicaid Services to establish and maintain the following:
- Enrollment and eligibility
- Plan management
- Small Business Health Options Program application
- Financial management
- Consumer support
Put in simpler terms, the state is not expanding Medicaid coverage to low-income adults. It is only introducing a different outlet, or “marketplace,” for citizens to apply and shop for affordable assistance.
According to numbers released by the federal Department of Health and Human Services, 877 people in Wisconsin signed up for health care plans during the first month of the marketplace.
Even with the introduction of the new streamlined enrollment process created by ObamaCare, Wisconsin’s state government has had contradicting ideas when it comes to adding and subtracting people from Medicaid.
In August of 2013, as reported by Biztimes.com, Governor Scott Walker cut more people from Medicaid than any other state.
An estimated 92,000 Wisconsin citizens, including 87,000 parents and caretaker relatives and 5,000 childless adults with incomes above the federal poverty level, lost Medicaid coverage.
Wisconsin is among only four other states that planned to cut Medicaid coverage last year. The others include Maine with 35,000 people cut from coverage, Vermont with 19,000 and Rhode Island with 6,700, according to BizTimes.com.
In the same breath, Walker moved to extend BadgerCare/HIRSP coverage by three months to those who would lose their care in January of 2014, as reported by NYTimes.com.
“Although this extension would help some, it will keep over 100,000 Wisconsinites (i.e. the BadgerCare waitlist) uninsured for three more months,” Chairwoman of the Walworth Affordable Care Act Awareness Steering Committee, Dr. Katherine Gaulke, said, “and that is three long months for flu season or for a person with diabetes who hasn’t been able to receive care or pay for medications.”
The extension in coverage was a response to a delay in legislation due to defections with the federal website, access.wisconsin.gov.
According to Steve Yaccino, of The New York Times, Walker said, “We’re talking about real people’s lives. I’m not going to let the failures of the federal government bring down people who are caught in between systems that just aren’t working right now.”
Wisconsin’s website was supposed to be up and running in December, but the deadline was stretched to the end of March.
It is due to this delay that Coburn said a State-Facilitated Marketplace may work better than the federal system Wisconsin has adopted.
“There are just so many levels of bureaucracy between an individual and coverage,” Coburn said. “If [the marketplace is] in your state, you have more control and it’s easier to get help if you have a problem.”
She pointed to Minnesota as an example of a state with an SFM and said it was a “much more organized effort.”
“They started outreach much sooner than Wisconsin,” Coburn said. “Everything was last minute in [this state].”
With the introduction of the FFM, many people who had BadgerCare lost their coverage at the end of March 2014.
BadgerCare used to provide coverage for pregnant women and children who were younger than 19, but the ACA has changed the rules so anyone with an income below 100 percent of poverty is eligible.
This will kick about 270,000 people off of BadgerCare, according to Johnson.
However, those with 100 to 400 percent above poverty will go to the marketplace and select insurance. It is estimated that 100,000 people will be added onto Medicaid this way.
The categories of insurance offered through the marketplace are broken down into five categories: Bronze, Silver, Gold, Platinum and Catastrophic.
Healthcare.gov suggests “plans in these categories differ based on how you and the plan share the costs of your care.” The site also states, “The categories have nothing to do with the amount or quality of care you get.”
However, the Director of Health for UW-Whitewater’s University Health & Counseling Services, Ruth Swisher, said she does not suggest purchasing lower than Platinum.
While all of the plans cover wellness and preventative care, “[with the lower plans] you will have a lot of out-of-pocket costs, and it will not be as robust,” Swisher said.
The out-of-pocket costs include money an individual must pay towards his or her care before an insurance company begins to pay its share. This money includes fees from deductibles, copayments and coinsurance.
The ACA’s affect on UW-Whitewater students
The law may also affect students of the University of Wisconsin-Whitewater.
For one thing, Coburn said students can benefit from the increases in preventative care.
“As part of the ACA, preventative care is covered without a copay,” Coburn said, “even if you’re on your parents’ insurance.”
However, things are not so simple when preventative care turns into a diagnosis.
“There are layers,” Coburn said. “The minute a checkup turns diagnostic, like if a polyp is removed during a colonoscopy, it’s a whole other beast.”
If young adults are not covered on their parents’ insurance, they have the option of applying for care at the marketplace.
According to a poll taken by the Kaiser Family Foundation Health Tracking Poll, nearly 80 percent of Americans under 30 have heard little to nothing about the marketplace.
A foundation called Young Invincibles is aimed at trying educate young people about their health insurance options.
As reported by Dana Sand, of USA Today, the deputy director of Young Invincibles, Jennifer Mishory, said students will be affected by the online marketplace in three significant ways:
- Students can enroll in plans without the threat of being denied coverage because of a pre-existing condition.
- Students who earn less than about $46,000 or families that earn less than $94,000 annually may be able to access free coverage through Medicaid or discounted coverage through monthly tax credits depending on the state and their exact income level.
- New plans will provide free preventive services, annual checkups, prescriptions and substance use disorder services.
On UW-Whitewater’s campus specifically, students have several options to choose from when it comes to obtaining health insurance.
As mentioned earlier, the ACA has made it possible for a young adult to remain on his or her parents’ plan as long as “the family can make it work financially,” Swisher said.
If a student is not covered through a family plan, he or she can apply for insurance on the marketplace or for plans offered through the university, which are provided through Nationwide Insurance.
The university’s plans, however, are expected to increase dramatically in price next fall.
The annual plan for this year, which ends in May, was $1,200 and is estimated to increase to more than $4,000 next year, Swisher said.
The increase in cost and the decrease in coverage have to do with the university’s plans being “voluntary,” meaning UW-Whitewater is not required to offer them through the University of Wisconsin system.
Not many students take advantage of plans offered through the university, so cost sharing is low. This is what makes the coverage rates so high.
“I’d like to see students sign a ‘hard waiver,’” Swisher said. “Students who have insurance through another mean would be waived out, but other students would need to sign up. This would force [an insurance company] to give us better rates and coverage.”
International students who come to study at UW-Whitewater, however, are required to sign up for a mandatory plan.
According to Swisher, these students have access to better plans, and they only have to pay $1,400 for coverage every year.
Hard waivers and mandatory plans have also been implemented by private universities throughout the state, “so we know it works,” Swisher said.
In addition, the ACA has created restrictions that include fines for students who choose to opt out of any coverage. Students will be fined $100 if they remain uncovered this year, and that price is expected to increase every year.
Swisher said she and other “task groups” on campus have presented the issues surrounding student healthcare to the Student Health Advisory Committee, and the Whitewater Student Government has also shown favor in a hard waiver.
The Board of Regents, however, has yet to progress the idea further.
“We have had our voices heard, but nothing has happened,” Swisher said. “I’m clearly in support of people having insurance, and I’m disappointed that [Wisconsin] is behind the times because other states are doing more.”
FFM processing in Jefferson and Walworth Counties
In order to help the citizens of Jefferson and Walworth Counties, there is a “regional enrollment network that works with the customers to assist them in applying at the marketplace,” Johnson said.
Jefferson County Human Services, in particular, employs five certified application counselors who help people apply for the marketplace.
This network works to give citizens free access to computers through the human services, two hospitals, free clinics and health departments.
“We are currently receiving large groups of applications that were sent to the marketplace last year and are now coming to Wisconsin to be processed,” Johnson said. “I have over 700 applications to look over.”
If an applicant is not eligible, however, the health and human services will still try to provide assistance.
“If you apply at accesswisconsin.gov or the marketplace and are ineligible, they will forward your application to another program,” Johnson said.
The people who are ineligible can find a contortion number, call the office in either Walworth or Jefferson County and set up a meeting with a certified application counselor.
The future of free clinics
With more and more people becoming insured, there is concern over the future of free clinics around the area.
“Uninsured people go to free clinics if they need health care, especially if they have chronic illnesses or just get sick,” Coburn said.
However, the goal of ObamaCare is not to insure every single American, Coburn said. The goal is to cut the number of those currently uninsured by half, therefore there will always be people who need the services offered by free clinics, she added.
The future of controversy
Coburn said she blames the recent controversies surrounding ObamaCare on “selective memory.”
When Medicare was first introduced in the 1960s, many were skeptical of its efficiency, according to Coburn. The Wisconsin Nursing Association, for which Coburn currently belongs, was one of the first and only organizations in the state to back the program.
“They were chastised by the medical associations,” Coburn said, “but nurses were [and still are] advocates for their patients.”
It is impossible to know if the controversial law will eventually become commonplace, like Medicare, and the ultimate affect of the ACA on Whitewater’s citizens is anything but predictable.
On one hand, elderly community members are being helped through a gap in their coverage, but the young and older adults are simultaneously gaining and loosing access to health care through Medicaid and other programs.
As Coburn explained, “It’s a complex law, and you can’t sum it up in a sound bite.”